CurrentUnitedHealthcarePolicy N/A

Prior Authorization Request Template — Specialty/Pharmacy Drugs

This document is a prior authorization request template used to collect beneficiary, prescriber, drug, and clinical information to support coverage decisions for specialty or pharmacy drugs under UnitedHealthcare. It affects prescribing providers and pharmacy benefit reviewers processing PA requests.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Request Template — Specialty/Pharmacy Drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form with drug details, requested length of therapy, and clinical justification including prior preferred drug failures or contraindications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4document sections

up to 365 daystherapy length options

6+clinical prompts

Coverage Criteria

Clinical justification for non-preferred drug coverage

Coverage consideration requires provider attestation and documentation of one or more clinical justifications:

note":"Provide patient age and explanation."},{"operator":"all","text":"Unique clinical indication supported by FDA approval or peer‑reviewed literature.

note":"Explain indication and provide general reference(s)."},{"operator":"all","text":"Unacceptable clinical risk associated with therapeutic change to a preferred agent.

note":"Explain the risk and rationale for continuing or initiating the non‑preferred therapy."}],"threshold":"1 of the listed justifications","text":"Any one of the listed clinical justifications is sufficient for consideration","note":"Provider must sign and date the form certifying the information is accurate and complete."}

This prior authorization form is used to request coverage for non‑preferred, specialty, or other pharmacy medications. Coverage consideration requires the provider to attest to and document one or more clinical justifications for the non‑preferred drug request (for example: failure of two preferred drugs or one if only one exists; allergic reaction or drug–drug interaction to preferred agents; unacceptable side effects or therapeutic failure; clinical contraindication/co‑morbid condition; age‑specific indication; FDA‑approved or literature‑supported unique indication; or unacceptable clinical risk from switching therapy). The completed form must include beneficiary and prescriber identifiers, the requested drug name/strength/quantity, the requested length of therapy, and explanatory clinical information as applicable.

Policy Summary

PayerUnitedHealthcare

PolicyPrior Authorization Request Template — Specialty/Pharmacy Drugs

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior authorization form with drug details, requested length of therapy, and clinical justification including prior preferred drug failures or contraindications.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Provider Actions and Submission Requirements

Prior Authorization

Prior Authorization Submission Requirements

Prior authorization is required. Submit a completed prior authorization form that includes the prescriber and beneficiary identifiers, drug name, strength, quantity requested, and length of therapy. Include clinical details supporting the request (diagnosis, relevant lab results, prior therapies and dates). Incomplete submissions may delay review.

Include beneficiary name, date of birth, and beneficiary ID
Include prescriber name, NPI, contact phone and extender info
Specify drug name, strength, quantity per 30 days, and requested length of therapy

Step Therapy

Step Therapy / Preferred Drug Failure Documentation

Document trials of required preferred drugs or provide documented reasons why trials are not appropriate. If two preferred drugs are required by policy, include dates and outcomes of both trials; if only one preferred drug is available, document failure of that one. List each preferred drug tried and the clinical reason for failure (lack of efficacy, adverse reaction, intolerance) or contraindication.

List preferred drugs tried with start and stop dates and reason for discontinuation
If only one preferred drug exists, document failure of that drug with clinical details

Documentation Required

Required Documentation on PA Form

Provide complete clinical justification on the PA form. Required documentation includes beneficiary identifiers, prescriber identifiers and signature, drug details (name, strength, quantity, duration), and detailed clinical rationale for medical necessity (diagnosis, prior treatments, contraindications, adverse reactions, relevant labs or imaging). Attach supporting records when applicable.

Beneficiary: name, DOB, member ID
Prescriber: name, NPI, contact phone, prescriber signature and date (signature mandatory)
Drug details: name, strength, quantity per 30 days, length of therapy

Denial Risk

Insufficient Clinical Justification Risks Denial

Insufficient clinical justification or missing documentation may result in denial or processing delays. Failure to document required trials, contraindications, or clinical rationale (including missing prescriber signature) increases the risk of denial. If additional information is requested, timely provider response is required to avoid denial.

Omissions commonly leading to denial: missing trial dates/outcomes, absent prescriber signature, lack of specific clinical details
Respond promptly to requests for additional information to prevent denial or delays

Step Therapy Requirements

Step	Requirement
1	Documentation that the member has failed two preferred drugs (or one if only one preferred drug is available). The form requires listing the preferred drugs failed and associated clinical details.
2	Provide clinical justification options as applicable: allergic reaction, drug–drug interaction (describe reaction), previous unacceptable side effect or therapeutic failure (provide clinical information), clinical contraindication/co‑morbidity/unique patient circumstance (provide clinical information), age‑specific indication (give patient age and explanation), unique clinical indication supported by FDA approval or peer‑reviewed literature (explain and provide reference), or unacceptable clinical risk associated with therapeutic change (explain).
3	Prescriber attestation: prescriber signature and date are mandatory on the form certifying the accuracy and completeness of the information provided.

OpenPayer

Prior Authorization Request Template — Specialty/Pharmacy Drugs

Coverage Criteria

Coding and Therapy Length

Provider Actions and Submission Requirements

Background

Step Therapy Requirements

Quantity Limits